Castleton Health Care Center: Call Light Out of Reach - IN
The woman, identified in inspection records only as Resident N, had chronic obstructive pulmonary disease, chronic kidney disease, heart failure, and arthritis. Her care plan noted impaired balance, limited mobility, pain, and shortness of breath. She refused to get out of bed. The plan called for staff to encourage her to use the call bell for assistance.
The call bell was not within her reach.
A state inspector visiting her room on September 17, 2025, at 12:18 p.m. found her lying in bed, the call light cord wrapped around the right side rail and hanging down the side of the mattress toward the floor. Resident N picked up her wooden stick and tried to reach the cord with it. She couldn't get it.
"Most of the time I can't reach my call light," she told the inspector. "I don't suffer too much not being able to reach it. I take my stick and start beating on the table, and they can hear me, and then they come."
She explained she couldn't turn over to reach the cord, and she couldn't get her hand around far enough to grab it. When she soiled her brief, she hit the bedside table or the side rail with the stick. She demonstrated this for the inspector while they spoke.
Staff had been in her room roughly an hour and a half before the inspector arrived. They had not moved the call light.
The inspector returned at 1:55 p.m. Resident N was still in bed, eating lunch. Someone had brought her the tray. The call light was still wrapped around the side rail, still hanging eight inches from the floor, still out of reach. She didn't know who had delivered her lunch. Whoever it was had not adjusted the cord.
Two minutes later, the unit manager walked in with the inspector. The unit manager untangled the cord from the rail and placed it within Resident N's reach. She acknowledged the call light should always be accessible and said the facility might need to get a clip or a different type of call light entirely.
The facility's own written policy, provided to inspectors two days later, stated that call lights must be within reach of the resident at all times, that staff must ensure the light is accessible before leaving a room, and that call lights should never be placed on the floor or the bedside stand.
The cord had been tied to the side rail and left there. Staff had entered the room, delivered a meal, and left. Nobody moved it.
Inspectors noted Resident N was moderately cognitively impaired, according to her most recent assessment. She had found her own solution: a stick, and the noise it made when she hit something hard enough.
"I can't get it in my hand and do anything," she said of the call light cord.
The inspection was conducted as a complaint investigation, tied to two separate intake reports. The violation was cited at a level of minimal harm, meaning inspectors determined no serious injury had occurred. Resident N, for her part, did not describe her situation as a crisis. She had adapted. She had a system.
The system was a piece of wood.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Castleton Health Care Center from 2025-09-23 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
CASTLETON HEALTH CARE CENTER in INDIANAPOLIS, IN was cited for violations during a health inspection on September 23, 2025.
Her care plan noted impaired balance, limited mobility, pain, and shortness of breath.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.